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All About Hypertension

Updated on August 29, 2015

Systolic blood pressure (SBP) of 140 mm Hg or more

Diastolic blood pressure (DBP) of 90 mm Hg or more

Taking antihypertensive medication

Classification of hypertension

SBP DBP

Optimal < 120 < 80

Normal < 130 85

High normal 130–139 85–89

Grade 1 (mild)

SBP 140–159 mm Hg

DBP 90–99 mm Hg

Grade 2 (moderate)

SBP 160–179 mm Hg

DBP 100–109 mm Hg

Grade 3 (severe)

SBP ≥ 180 mm Hg

DBP > 110 mm Hg

Isolated systolic hypertension

Grade 1

SBP 140–159 mm Hg

DBP < 90 mm Hg

Grade 2

SBP ≥ 160 mm Hg

DBP < 90 mm Hg

Aetiology

Essential hypertension

in more than 95%

Secondary hypertension

in 5% of cases

Causes of secondary hypertension

Alcohol

Obesity

Pregnancy (pre-eclampsia)

Renal disease

Parenchymal renal disease, particularly glomerulonephritis

Renal vascular disease

Polycystic kidney disease

Drugs

Oral contraceptives containing oestrogens

Corticosteroids

NSAIDs

Coarctation of the aorta

Causes of secondary hypertension

Endocrine disease

Phaeochromocytoma

Cushing’s syndrome

Primary hyperaldosteronism(Conn’s syndrome)

Hyperparathyroidism

Acromegaly

Primary hypothyroidism

Thyrotoxicosis

History

Detailed history regarding:

Extent of end-organ damage (e.g, heart, brain, kidneys, eyes)

Assessment of patients’ cardiovascular risk status

Exclusion of secondary causes of hypertension

Family history

Lifestyle (exercise, salt intake, smoking habit, cholesterol)

Careful history will identify drug- or alcohol-induced hypertension

Symptoms of secondary causes of hypertension as phaeochromocytoma (paroxysmal headache, palpitation and sweating)

Complications of coronary artery disease (e.g. Angina, breathlessness)

Identify end-organ damage

Heart:

left ventricular hypertrophy,

angina/previous myocardial infarction,

previous coronary revascularization, and heart failure

Brain:

stroke or transient ischemic attack,

dementia

Chronic kidney disease

Peripheral arterial disease

Retinopathy

Physical Examination

An average of 3 blood pressure readings taken using a mercury manometer

On the first visit, BP should be checked in both arms and in one leg to diagnose coarctation of aorta or subclavianartery stenosis.

Eye examination

Palpation of all peripheral pulses. Absent, weak, or delayed femoral pulses suggests coarctation of aorta

Neck for carotid bruits, distended veins, or enlarged thyroid gland.

Renal artery bruit over upper abdomen suggests renal artery stenosis.

Cardiac examination to evaluate signs of LVH.

displacement of apex

sustained and enlarged apical impulse

presence of S4

Enlarged kidneys (polycystic kidney disease)

Characteristic facies of Cushing’s syndrome

Important risk factors

Central obesity

Hyperlipidaemia (tendon xanthomas )

Target organ damage

Blood vessels

Structural changes in vasculature aggravate hypertension by increasing peripheral vascular resistance and reducing renal blood flow

major risk factor in pathogenesis of

aortic aneurysm

aortic dissection

Central nervous system

Stroke may be due to cerebral haemorrhage or infarction.

Carotid atheroma and TIAs

Subarachnoid haemorrhage

Hypertensive encephalopathy is a rare condition

High BP and neurological symptoms

Papilloedema is common.

The neurological deficit is usually reversible if hypertension is properly controlled.

Retina

Hypertensive retinopathy

Grade 1: Arteriolar thickening, tortuosity and increased reflectiveness (‘silver wiring’)

Grade 2: Grade 1 plus constriction of veins at arterial crossings (‘arteriovenous nipping’)

Grade 3: Grade 2 plus evidence of retinal ischaemia (flame-shaped or blot haemorrhages and ‘cotton wool’exudates)

Grade 4: Grade 3 plus papilloedema

Heart

Coronary artery disease.

Left ventricular hypertrophy with a forceful apex beat and fourth heart sound.

Atrial fibrillation due to diastolic dysfunction caused by left ventricular hypertrophy or the effects of coronary artery disease.

Left ventricular failure

Kidney

Long-standing hypertension may cause proteinuria and progressive renal failure by damaging the renal vasculature.

‘Malignant’ or ‘accelerated’ phase
hypertension

High BP and rapidly progressive end organ damage such as

Retinopathy (grade 3 or 4)

Renal dysfunction (especially proteinuria)

Hypertensive encephalopathy

Left ventricular failure

If left untreated, death occurs within months.

Investigation of all patients

Urinalysis for blood, protein and glucose

Blood urea, electrolytes and creatinine

Blood glucose

Serum total and HDL cholesterol

Thyroid function tests

12-lead ECG (left ventricular hypertrophy, coronary artery disease)

Investigation of selected patients

Urinary catecholamines: to detect possible phaeochromocytoma

Urinary cortisol and dexamethasone suppression test: to detect possible Cushing’s syndrome

Plasma renin activity and aldosterone: to detect possible primary aldosteronism

Chest X-ray: to detect cardiomegaly, heart failure, coarctation of the aorta

Ambulatory BP recording: to assess borderline or ‘white coat’ hypertension

Echocardiogram: to detect or quantify left ventricular hypertrophy

Renal ultrasound: to detect possible renal disease

Renal angiography: to detect or confirm presence of renal artery stenosis

Management

Objective of antihypertensive therapy is to reduce the incidence of adverse cardiovascular events

Coronary artery disease

Stroke

Heart failure

Non-drug therapy

Correcting obesity

Avoid alcohol intake

Restricting salt intake

Taking regular physical exercise

Increasing consumption of fruit

Quitting smoking

Eating oily fish

Diet low in saturated fat

Antihypertensive drugs

Thiazide and other diuretics

ACE inhibitors

Angiotensin receptor blockers

Calcium channel antagonists

Beta-blockers

Labetalol and carvedilol

Other drugs

Thiazide and other diuretics

Used as monotherapy or can be administered with other antihypertensive agents

Inhibit reabsorption of sodium and chloride mostly in the distal tubules

Hydrochlorothiazide --doses ranging from 12.5-50 mg.

Chlorthalidone --doses ranging from 25-100 mg

Furosemide --The initial dose 40 mg

ACE inhibitors

Inhibit conversion of angiotensin I to angiotensin II

Side-effects include

first-dose hypotension, cough, rash, hyperkalemia and renal dysfunction

Used with particular care in patients with impaired renal function and renal artery stenosis

Enalapril 20 mg daily

Ramipril 5–10 mg daily

Lisinopril 10–40 mg daily

Angiotensin receptor blockers

Block the angiotensin II type I receptor and have similar effects to ACE inhibitors

do not cause cough

Valsartan 40–160 mg daily

Losartan –25-100mg daily

Irbesartan 150–300 mg daily

Calcium channel antagonists

Effective and well-tolerated in older people

Side-effects include flushing, palpitations and fluid retention

Amlodipine 5–10 mg daily

Nifedipine 30–90 mg daily

Diltiazem 200–300 mg daily

Verapamil 240 mg daily

Rate limiting CCB can be useful when hypertension coexists with angina

Beta-blockers

No longer used as first-line except in patients with another indication for the drug e.g. angina

Metoprolol 100–200 mg daily

Atenolol 50–100 mg daily

Bisoprolol 5–10 mg daily

Labetalol and carvedilol

Combined β- and α-adrenoceptor antagonists

Labetalol-- 200 mg–2.4 g daily in divided doses

carvedilol -- 6.25–25 mg twice daily

Other drugs

Prazosin (0.5–20 mg daily in divided doses)

Doxazosin (1–16 mg daily)

Hydralazine (25–100 mg twice daily)

Side-effects include

first-dose and postural hypotension

headache

tachycardia

fluid retention

Recommendations

Goal is 139/89 mm Hg or less

Stage 1 hypertension: treated with lifestyle modifications and, if needed, a thiazide diuretic

Stage 2 hypertension: treated with a combination of a thiazide diuretic and an ACE inhibitor, an angiotensinreceptor blocker, or a calcium channel blocker

Patients who fail to achieve BP goals: Medication doses can be increased and/or a drug from a different class can be added to treatment

Choice of antihypertensive drug

Heart failure: Diuretic, ACE inhibitor, ARB, beta-blocker, aldosterone antagonist,

Postmyocardial infarction: Beta-blocker, ACE inhibitor, aldosterone antagonist

High coronary disease risk: Beta-blocker, ACE inhibitor, CCB, Diuretic

Diabetes: ACE inhibitor, ARB, CCB, Diuretic, beta-blocker

Chronic kidney disease: ACE inhibitor, ARB

Emergency treatment of accelerated phase or malignant hypertension

Lowering BP too quickly may compromise tissue perfusion (due to altered autoregulation)

Cause cerebral damage, including occipital blindness, and precipitate coronary or renal insufficiency.

Even in the presence of cardiac failure or hypertensive encephalopathy, a controlled reduction to a level of about 150/90 mmHg over a period of 24–48 hours is ideal.

Oral drug therapy

Intravenous or intramuscular labetalol (2 mg/min to a maximum of 200 mg),

Intravenous glyceryl trinitrate (0.6–1.2 mg/hr),

Intramuscular hydralazine (5 or 10 mg boluses repeated at half hourly intervals)

Intravenous sodium Nitroprusside (0.3–1.0 μg/kg body weight/min)

require careful supervision, preferably in a high dependency unit.

Adjuvant drug therapy

Aspirin: indicated in

patients 50 years or over

target organ damage

diabetes

10-year coronary artery disease risk of at least 15%

Statins: indicated in

established vascular disease

hypertension with a high risk of developing cardiovascular disease

Refractory hypertension

Non-adherence to drug therapy

Inadequate therapy

Failure to recognize an underlying cause such as

Renal artery stenosis

Pheochromocytoma

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